An insurance network, also known as a provider network, is a collection of healthcare providers, such as doctors, hospitals, clinics, and other medical facilities, who have agreed to provide medical services to members of a specific insurance plan at discounted rates.
Insurance companies formed this network of doctors and other healthcare providers to provide medical care to their members while also helping them save money.
They set up these networks to control costs and ensure that their policyholders have access to a variety of healthcare services. Every health insurance plan offered through employers or individual marketplaces includes a provider network.
How do Insurance Networks Work?
They work by forming partnerships between health insurance companies and specific healthcare providers, creating a group of providers who have agreed to provide services at discounted rates to the company’s policyholders.
When a healthcare provider or facility joins a health insurance network, they agree to accept a lower fee for their services and treatment. Those who are affiliated with a health insurance network are referred to as in-network providers.
This network unites a diverse group of healthcare professionals from various specialities and facilities under one health plan. This then provides health plan members with a selection of providers to meet their diverse needs.
It can also refer to independent agencies that have banded together to pool premiums and gain access to benefits typically reserved for larger organizations. They can impact the cost and quality of care for insured members.
Types of Insurance Networks
There are a variety of insurance networks. However, there are four major types:
- Exclusive Provider Organization (EPO): It requires you to use in-network healthcare providers and does not cover out-of-network expenses, except in emergencies.
- Health Maintenance Organization (HMO): This plan typically restricts a participant’s coverage to doctors contracted with or working for the HMO. It usually only covers in-network benefits. To receive in-network benefits, you must only seek care from providers within your network. With an HMO plan, you are responsible for paying for all care provided by non-network/out-of-network providers, unless the care is pre-authorized or for emergency or urgent care.
- Point of Service (POS): It requires you to select a PCP and receive referrals to specialists, but it also provides out-of-network benefits. When using this plan, participants pay less when they use providers from the plan’s network.
- Preferred Provider Organization (PPO): It is intended to give you the most flexibility in selecting your healthcare providers by including both in-network and out-of-network benefits. If you choose to receive care from an in-network/preferred provider, your out-of-pocket medical expenses will be minimized.
However, you may still seek medical treatment from out-of-network/non-preferred healthcare providers.
Why are Insurance Networks Important?
They are important for several reasons.
- Cost savings: They negotiate lower rates with healthcare providers, which benefits both the insurance company and the policyholder. Staying within the network allows policyholders to access healthcare services at a lower cost than going out of the network.
- Access to quality care: They usually include a comprehensive list of healthcare providers who have been screened for quality of care. Policyholders can receive high-quality healthcare services by working with in-network providers.
- Coordination of care: They frequently have systems in place to help coordinate care among different healthcare providers, ensuring that patients receive comprehensive and integrated care. This may result in better health outcomes for patients.
- Transparency: Provides clear information on which healthcare providers are in-network, allowing policyholders to better understand their coverage and get the care they require.
Knowing that you are covered by a reputable insurance network can provide you with peace of mind in the event of a medical emergency or illness.
How to Check Your Insurance Network
To check your insurance network online, take these steps:
- Go to the official website of a reputable company, such as Cigna at cigna.com
- If you have an online account, log in with your username and password. If you do not already have an account, you can create one by entering your personal information and policy details.
- Once you have logged in to your account, go to the section that contains information about your insurance coverage.
- This section includes a tool or search feature for looking up in-network healthcare providers.
To find a specific provider, you can search by location, speciality, provider name, or facility type.
Frequently Asked Questions
Below are some frequently asked questions.
How do I Determine Whether a Provider is In-Network?
Consult your insurance provider directly to see if they are in-network. You can also contact the provider’s billing department to find out whether your insurance will cover the costs if you use their services.
Is it More Expensive to Visit a Provider Outside of my Health Plan’s Network?
Yes, going to an out-of-network provider usually results in a higher bill. Keep in mind that some health plans do not cover non-emergency services from out-of-network providers. Check your benefits before choosing a doctor or other health care provider.
Why do Health Insurers use Provider Networks?
Insurers restrict the healthcare providers that their members can use to those who agree to accept lower fees for their services. In exchange, providers can see more patients. Consequently, if you select a plan with a narrow network, you will pay less.
Conclusion
It is essential to review the details of your health plan’s network, preferably before you use your coverage. Make sure you understand whether your plan covers out-of-network care (many do not).
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